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psnet.ahrq.gov/node/47829/psn-pdf
March 27, 2019 - The impact of internal service quality on preventable
adverse events in hospitals.
March 27, 2019
Zheng S, Tucker AL, Ren ZJ, et al. The Impact of Internal Service Quality on Preventable Adverse Events
in Hospitals. Production Operations Manag. 2017;27(12):2201-2212. doi:10.1111/poms.12758.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/34902/psn-pdf
February 27, 2009 - Hospital rules-based system: the next generation of
medical informatics for patient safety.
February 27, 2009
Wilson JW, Oyen LJ, Ou NN, et al. Hospital rules-based system: the next generation of medical informatics
for patient safety. Am J Health Syst Pharm. 2005;62(5):499-505.
https://psnet.ahrq.gov/issue/hospit…
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psnet.ahrq.gov/node/842431/psn-pdf
January 11, 2023 - Confronting racism in pediatric care.
January 11, 2023
Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685.
doi:10.1377/hlthaff.2022.01157.
https://psnet.ahrq.gov/issue/confronting-racism-pediatric-care
Racism is a patient safety issue that is gaining the increased attention ne…
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psnet.ahrq.gov/node/837153/psn-pdf
January 01, 2025 - Annual Communication, Apology, and Resolution (CARe)
Forum.
October 29, 2024
Betsy Lehman Center for Patient Safety.
https://psnet.ahrq.gov/issue/annual-communication-apology-and-resolution-care-forum
Communication and resolution programs are a promising strategy for successful management of
relationships a…
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psnet.ahrq.gov/node/34660/psn-pdf
December 24, 2008 - Building a learning organization.
December 24, 2008
Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91.
https://psnet.ahrq.gov/issue/building-learning-organization
Garvin, a Harvard Business School professor, postulates that for organizations to truly improve over time
and succeed, they ne…
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psnet.ahrq.gov/node/837907/psn-pdf
August 24, 2022 - ISMP Guidelines for Safe Medication Use in Perioperative
and Procedural Settings.
August 24, 2022
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
https://psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings
Medication errors associated with surgery and…
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psnet.ahrq.gov/node/47386/psn-pdf
September 19, 2018 - Active-shooter response at a health care facility.
September 19, 2018
Inaba K, Eastman AL, Jacobs LM, et al. Active-Shooter Response at a Health Care Facility. N Engl J Med.
2018;379(6):583-586. doi:10.1056/NEJMms1800582.
https://psnet.ahrq.gov/issue/active-shooter-response-health-care-facility
Physical and verbal…
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psnet.ahrq.gov/node/39977/psn-pdf
November 03, 2010 - Structural empowerment and patient safety culture
among registered nurses working in adult critical care
units.
November 3, 2010
Armellino D, Griffin MTQ, Fitzpatrick JJ. Structural empowerment and patient safety culture among
registered nurses working in adult critical care units. J Nurs Manag. 2010;18(7):796-803…
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psnet.ahrq.gov/node/45223/psn-pdf
September 27, 2017 - Hospital safety climate and safety behavior: a social
exchange perspective.
September 27, 2017
Ancarani A, Di Mauro C, Giammanco MD. Hospital safety climate and safety behavior: A social exchange
perspective. Health Care Manage Rev. 2017;42(4):341-351. doi:10.1097/HMR.0000000000000118.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/39978/psn-pdf
November 03, 2010 - Creating an improvement culture for enhanced patient
safety: service improvement learning in pre-registration
education.
November 3, 2010
Christiansen A, Robson L, Griffith-Evans C. Creating an improvement culture for enhanced patient safety:
service improvement learning in pre-registration education. J Nurs Manag…
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psnet.ahrq.gov/node/42506/psn-pdf
August 28, 2013 - Foundations for teaching surgeons to address the
contributions of systems to operating room team conflict.
August 28, 2013
Rogers DA, Lingard LA, Boehler ML, et al. Foundations for teaching surgeons to address the contributions
of systems to operating room team conflict. Am J Surg. 2013;206(3):428-32.
doi:10.1016/…
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psnet.ahrq.gov/node/38459/psn-pdf
October 03, 2012 - Identifying opportunities for quality improvement in
surgical site infection prevention.
October 3, 2012
Gagliardi AR, Eskicioglu C, McKenzie M, et al. Identifying opportunities for quality improvement in surgical
site infection prevention. Am J Infect Control. 2009;37(5):398-402. doi:10.1016/j.ajic.2008.10.027.
h…
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psnet.ahrq.gov/node/44718/psn-pdf
November 25, 2015 - Beyond the Quick Fix: Strategies for Improving Patient
Safety.
November 25, 2015
Baker GR. Toronto, ON: Institute of Health Policy, Management and Evaluation, University of Toronto;
2015.
https://psnet.ahrq.gov/issue/beyond-quick-fix-strategies-improving-patient-safety
The 2004 Canadian Adverse Events Study helpe…
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psnet.ahrq.gov/node/46636/psn-pdf
January 24, 2018 - Drug shortages continue to compromise patient care.
January 24, 2018
ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4.
https://psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
Drug shortages are known to disrupt the safety of care. This newsletter article reports the res…
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psnet.ahrq.gov/node/72786/psn-pdf
February 24, 2021 - Drug shortages amid the COVID-19 pandemic.
February 24, 2021
Bookwalter CM. US Pharmacist. 2021;46(2):25-28.
https://psnet.ahrq.gov/issue/drug-shortages-amid-covid-19-pandemic
COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of
supply-chain fact…
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psnet.ahrq.gov/node/38036/psn-pdf
January 02, 2017 - Debriefing medical teams: 12 evidence-based best
practices and tips.
January 2, 2017
Salas E, Klein C, King HB, et al. Debriefing medical teams: 12 evidence-based best practices and tips. Jt
Comm J Qual Patient Saf. 2008;34(9):518-527.
https://psnet.ahrq.gov/issue/debriefing-medical-teams-12-evidence-based-best-pr…
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psnet.ahrq.gov/node/73996/psn-pdf
October 29, 2021 - Patient, Medical, and Legal Perspectives of Unsafe Care.
October 20, 2021
Patient Safety Movement. October 29, 2021.
https://psnet.ahrq.gov/issue/patient-medical-and-legal-perspectives-unsafe-care
Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This
webinar …
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psnet.ahrq.gov/node/60533/psn-pdf
May 27, 2020 - What constitutes effective team communication after an
error?
May 27, 2020
Hart WM, Doerr P, Qian Y, et al. What constitutes effective team communication after an error? AMA J
Ethics. 2020;22(4):E298-E304. doi:10.1001/amajethics.2020.298.
https://psnet.ahrq.gov/issue/what-constitutes-effective-team-communication-a…
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psnet.ahrq.gov/node/60288/psn-pdf
April 29, 2020 - Do some surgical implants do more harm than good?
April 29, 2020
Groopman J. New Yorker Online. April 13, 2020.
https://psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good
Medical devices support quality of life but must be designed appropriately and managed carefully to ensure
safety over time.…
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psnet.ahrq.gov/node/39108/psn-pdf
November 18, 2009 - Missed opportunities to initiate endoscopic evaluation for
colorectal cancer diagnosis.
November 18, 2009
Singh H, Daci K, Petersen L, et al. Missed opportunities to initiate endoscopic evaluation for colorectal
cancer diagnosis. Am J Gastroenterol. 2009;104(10):2543-2554. doi:10.1038/ajg.2009.324.
https://psnet.a…